A 65 yr old male with ckd

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CASE;
 Jella Thejaswi , 8th sem
Roll no. 59


A 65 yr old male from Nalgonda farmer by occupation came to the hospital for maintenance dialysis 

HOPI:

Patient was apparently asymptomatic 20 years back then he noticed yellowish discolouration over sclera and urine and decreased urine output then he went to a hospital.Investigations are done and  diagnosed as Jaundice.

At the same time he also diagnosed as right kidney damage. so that 3 episodes of dialysis was done in a week.


For the next 10 years he was normal.
 
After 10 years he went for a normal check up and he diagnosed with diabetes and Hypertension.From then he is on medications.
For 8 years he is on oral diabetic drugs.And from  2 years he is on insulin.( Human Actrapid insulin along with Lantus )

2 months back he came to the hospital with decreased urine output and pus the urine, SOB (grade 1), back pain . For which he came to know that there is left kidney damage. From then he is on dialysis twice a week. Till now 13 episodes are done.

3 days back there is decreased urine output, back pain for which he came to the hospital.


 
PAST HISTORY:
Known case of Diabetes and Hypertension since 10 years

PERSONAL HISTORY
Routine history :He wakes up at 6 am in the morning and eats breakfast at around 9 am and works as shopkeeper and then lunch at 1pm takes a nap in the afternoon. Drinks tea in the evng and chapathi as dinner at 8 pm. Sleeps at 10 pm.

  Diet : Mixed
  Appetite: Good
  Bowel and bladder movements: Regular
  Sleep : Adequate
  Addictions : Consumption of alcohol since 40 years and   stopped 15 years back 
   No smoking.

GENERAL EXAMINATION
      Patient was conscious, cooperative.Moderetly built and nourished.Well oriented to time, place and person.

 pallor present
No icterus 
No Cyanosis
No clubbing 
No generalized lymphadenopathy
 Pitting Pedal edema present









VITALS:
Temperature ;  afebrile

RR;20cycles/min   

PULSE;80bpm

GRBS;210mg%

Spo2; 100 at room temperature

BP; 130/80 mm Hg


SYSTEMIC EXAMINATION;

Cardiovascular system- 
     s1 and S2 are heard ,no murmurs are heard

Respiratory system:
    trachea central, 
    all quadrants of chest moves equally with respiration.
    Breath sounds- bilateral normal
    Vesicular breath sounds are heard.


Central nervous system- 
     Patient was conscious, coherent and cooperative
     Speech was normal.
     No slurred speech.

Abdominal system:

Inspection:
       On inspection abdomen is flat, symetrical,and slightly distended.
   Umbilicus is centre and inverted
   No scars,engorged veins are seen.
   All 9 regions of abdomen are equally moving with respiration.

Palpation:
      On palpation abdomen is soft and non tender
.On bimanual examination of kidney is not palpable.All inspectory findings are confirmed.

Percussion:no shifting dullness, no fluid thrills
.
Auscultation:normal bowel sounds are heard.



INVESTIGATIONS:













Provisional diagnosis :: CKD

TREATMENT:
Salt restriction less than 2.4 gm /day
Fluid restriction less than 1 litre/day
Tab Nodosis po/Bd
Tab shelcal po/Bd
Orofer XT po/bd
Tab Lasix po/Bd
Tab biop3 weekly once.









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